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Re o -+spection Report Number <br /> � Waste Tireftey & Inspectionp � <br /> Cal Rec cle State of California <br /> Y calRecycle181(Rev.10/10) Survey Form - Page 1 11 - 1176382 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ -- _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ,1 _ I Inspection Type(Fill one) <br /> Site Suffix: "( 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Identifier. �(,t' n 30 )A1 CO (,�� <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad res <br /> al-kku S _ COJ 1,�(q so; <br /> j� Inspection Date <br /> S�d`p�'"'• 11 r�v� 5 ��"�p Time In Time Out l J <br /> Business Rep Title tl ®AM 1 u AM <br /> I O 1 0 PM J O 1 0 PM <br /> S A - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) i n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> U( b ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station ® Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> iE <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ '- -11_ �J I z <br /> Comments ' tS C�1C412� �A�n +O I I-( 1I—n� <br /> _J <br /> \1\3 (A A r\ <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> sin s ep's ig a ure Phone Number Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � � EXAMPLE 1 2 3 <br /> - <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />